NURSING PATIENT CARE POLICY & PROCEDURE
December 29, 2017
Policy #: 8.32A
Title: Privileges for Inpatient Psychiatry
To define privileges on the psychiatric unit, and the process of granting privileges to
leave the locked unit. These privileges are for short periods of time on hospital
grounds. For passes or leaves, see UW Health Clinical Policy 2.3.27, Inpatient
Privileges for Inpatient Psychiatry patients require an order from the attending
III. STATUS DEFINITIONS
A. Unit Only
1. Restrict: Patient is restricted to the unit at all times.
B. Off-Unit on Hospital Grounds Only
1. S/S (Staff/Student): Patient may leave unit but only if accompanied by
staff or medical/nursing student. This status is usually assigned to allow
patient to complete diagnostic testing off-unit.
2. RA (Responsible Adult): Patient must be accompanied by a responsible
person over the age of 18 (this excludes other patients or other patient’s
3. Full x 15: Patient may leave the unit alone for 15-minute periods.
4. Full x 30: Patient may leave the unit alone for 30-minute periods.
5. Full: Patient may leave the unit alone for up to one (1) hour.
A. Guidelines for Establishing Full Status
1. The Psychiatry attending will make the determination of status in
consultation with the treatment team.
2. Patients admitted under an emergency detention will be restricted to the
unit, at a minimum, until their probable cause hearing.
3. Prior to status determination, the patient is assessed for safety and ability
to follow directions.
4. The patient must have no recent elopement risk.
5. The patient must have no suicidal/self-harm behavior for a minimum of 24
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6. The patient must have no homicidal or assaultive behavior for a minimum
of 24 hours.
7. The above information will be documented as needed by the physician in
the patient’s clinical record.
B. Guidelines for Revocation of Full Status
1. Full status may be revoked if any of the following occur:
a. Suicidal or self-harm behavior
b. Assaultive, threatening, homicidal or abusive behavior
c. Extreme agitation, out of control behavior, disorganization of
thought, confusion or inability to follow directions
d. Drug or alcohol use
e. Recommendations from hospital security
f. Institution of 10-minute checks
g. Institution of aggression precautions
h. Elopement and/or institution of elopement precautions
i. Returning to unit with hidden, potentially harmful objects or
C. A restrictive status may be initiated by the assigned Registered Nurse (RN) or
Care Team Leader at any time, but resumption of full status will involve
discussion by the treatment team at a routine meeting.
D. Elopement Procedure
1. Elopement is defined as a patient walking away from the hospital without
an approved pass status or failing to return upon completion of approved
time limit. If an elopement occurs, search the unit, general areas of the
hospital, and areas immediately outside of the hospital.
a. If unable to locate patient, immediately notify Security at 890-
5555. Be prepared to offer a description of the patient: name, age,
height, weight (approx.), color of hair, facial hair or not, type of
clothes and color patient was wearing, any outstanding identifying
descriptions. Inform Security of the patient’s legal status:
voluntary or involuntary; commitment/order to treat. Offer any
information about where you think patient might have gone.
b. Determine if campus police should be notified (262-4524), and if
so, who will make the notification, security or inpatient psychiatry
staff. UWPD and B6/5 staff will determine if additional police
departments should be notified.
c. Notify the Nursing Coordinator on pager 7576.
d. Notify Psychiatry resident on call on pager 0079.
e. Determine if it is appropriate to notify anyone else that the patient
has eloped, such as family, county agency, a community support
program, a case manager, or patient’s caregiver(s).
f. Document events in the clinical record.
g. Complete a Patient Safety Net.
h. If patient returns, notify those who were previously notified and
document in clinical record that the patient has returned. If the
patient is returned by police, document any information they may
E. Resumption of Full Status
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1. A 24-hour evaluation period may be required after the incident which
prompted revocation to allow stabilization of behaviors. Assessment by
the treatment team will be completed the following morning.
a. The patient’s status is ordered by the attending physician and
reflects the decision of the treatment team. Patient status is re-
evaluated and changed by the treatment team. Patients can ask for
an increase in off-unit status at daily treatment team rounds.
b. Patient may verify his/her status through the team nurse.
c. Off-unit times are scheduled to avoid conflict with therapies,
meals and medication times.
d. Patients must sign in and out each time he/she enters or leaves the
unit. Even though a patient is leaving the unit, at no time should
staff assist with smoking supplies. Please refer to Nursing Patient
Care Policy 8.31A, Safety Considerations for the Admission
Procedure on Inpatient Psychiatry (Adult).
e. Psychiatry (B6/5) staff will inform the patients that University
Hospital is a smoke free/tobacco-free campus and smoking is not
allowed on the grounds.
V. UW HEALTH CROSS REFERENCES
A. UW Health Clinical Policy 2.3.27, Inpatient Absence,
B. UW Health Administrative Policy 1.41, Smoke Free/Tobacco Free Workplace
C. Nursing Patient Care Policy 8.31A, Safety Considerations for the Admission
Procedure on Inpatient Psychiatry (Adult)
VI. REVIEWED BY
Nurse Manager, Inpatient Psychiatry
Nursing Patient Care Policy and Procedure Committee, December 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive